Scaling Up Nutrition:

Full text

(1)

 

Scaling Up Nutrition:

The UK’s position paper on undernutrition

September 2011

(2)

The UK’s position paper on undernutrition

September 2011

(3)

CONTENTS

Contents

Foreword

Executive summary

Acronyms and abbreviations

 

Chapter 1: WHY we are scaling up nutrition

1.1 The scale of the challenge

... 6

1.2 Global risks

... 7

1.3 Global opportunities

... 8

    Chapter 2: HOW we will work 2.1 Working in partnership

... 11

2.2 Tackling the immediate causes

... 11

2.3 Addressing the underlying causes

... 12

2.4 Strengthening monitoring and evaluation

... 15

2.5 Building the evidence base

... 16

2.6 Building our skills and capacity

... 16

    Chapter 3: WHAT results we will deliver 3.1 Reaching more adolescent girls, pregnant women and children under five years of age with nutrition specific interventions ... 19

3.2 Delivering greater impact from nutrition sensitive programmes ... 21

3.3 Building a more effective international response to undernutrition... 22

3.4 Identifying new solutions to undernutrition on the basis of what works ... 25

(4)

FOREWORD

Foreword

In a world of some seven billion people, one billion go hungry every year. Another billion exist on diets that are deficient in vitamins and minerals. More than one in ten children are acutely malnourished.

 

The implications of these stark facts were brought home to me last year when I attended an event, convened by Ireland and the United States in the margins of the UN General Assembly. It was clear that undernutrition is one of the biggest threats to humanity’s future; it is outrageous that any little child should die from starvation in our world today. I returned to the UK determined that Britain would do more to tackle the scourge of undernutrition.

Over the past 12 months DFID has dramatically scaled up its work in this area. This paper demonstrates the full extent of that activity and sets out details of those

programmes that are being designed to meet the needs identified by the Bilateral Aid Review that we commissioned last year.

In particular, we are putting more money into specific services such as improving vitamin and mineral intake and supporting breastfeeding. This is a critical first step which will deliver significant and immediate results.

I saw some of those results in action when I visited Somaliland earlier this year and met a three-year old girl who had been on the verge of starvation. Thanks to the emergency nutrition support provided by Britain she was beginning to show signs of recovery.

Yet important though this support is, it is only part of the answer. Chronic undernutrition is born of many factors, including poor health, cultural issues, the status of women, low incomes, and ultimately, a dearth of concerted effort to address it. Any solution will need to take account of all these complexities.

To tackle undernutrition we need smart policies and programmes where impact is carefully analysed, measured and reported in a way that allows others to learn from the experience. This paper explains how we plan to meet those goals.

The current crisis in the Horn of Africa is a constant reminder of our failure to intervene early and prevent undernutrition before it reaches crisis levels. We are also faced with an even greater challenge: that of feeding 9 billion people by 2050 while at the same time protecting our planet. The British people can be proud that this Government is determined to rise to that challenge and to urge other countries to follow our lead. Undernutrition is indeed a scourge in our world. It will not be solved in one generation or by one country, but here and now we can begin to tackle it.

   

Secretary of State for International Development - Rt. Hon Andrew Mitchell MP

(5)

EXECUTIVESUMMARY

Executive summary

Why the UK is scaling up to reduce global undernutrition

Levels of global hunger are unacceptable. One billion people go hungry every year and a further one billion do not get enough vitamins and minerals. 195 million children under five years of age are chronically malnourished and more than 1 in 10 children are acutely malnourished. One third of all child deaths are linked to undernutrition.

Without action, these numbers will increase. The global population is set to rise to nine billion by 2050, from nearly seven billion today. Ensuring that food is affordable, protecting the poor from food price peaks and troughs and achieving global access to food are key challenges for the future.

The time to act is now, and we are well placed to have an impact because we know what to do and when to make a difference. Intervening in the first 1,000 days after conception will stop the irreversible effects of undernutrition. Second, a new global movement, Scaling Up Nutrition (SUN), is providing political

momentum and coordinated support. Moreover, some countries have paved the way by already achieving fast reductions in undernutrition, providing learning and experience for others.

What we will achieve

The UK’s aid programme will reach 20 million children under five years of age during the period 2011–2015. This will be achieved in two ways:

First, we will scale up nutrition-specific interventions to address the immediate causes of undernutrition because these are the best value for money. Thirteen proven nutrition interventions, if delivered at scale, could together reduce stunting by one third globally. These include for example, preventing and treating vitamin and mineral deficiency and support to

breastfeeding. Through these interventions we will reach more adolescent girls, pregnant women and children under five years of age. For example, in Nigeria and India our new nutrition programmes will reach more than 10 million children under five years of age.

Second, because nutrition-specific interventions will only reduce global stunting by one third, the remaining two thirds will need to be tackled through nutrition sensitive development. This involves adjusting and re-designing programmes across a range of sectors including agriculture, environmental health and cash transfer programmes to ensure that they deliver nutrition results. For example, we are integrating nutrition results into our programmes in Bangladesh, Zambia and India, as well as providing support to the scale up of fortified foods in Zambia and Tanzania which will reach millions.

(6)

EXECUTIVE SUMMARY

UK influence to build an effective international response

We cannot do this alone. The scale of the challenge ahead requires global concerted action. We will:

Support Scaling Up Nutrition (SUN) internationally and at country

level to mobilise financial and technical resources to scale up nutrition interventions for improved nutrition at country level.

Promote a leadership structure for Scaling Up Nutrition (SUN) that

involves all stakeholders, including civil society and the private sector.

Support the private sector to ensure we are delivering results at a

much greater scale. For example, through our support to the Global Alliance for Improved Nutrition (GAIN) they will reach more than 60 million people with fortified foods.

Support the multilateral agencies which have a role to play in tackling

undernutrition to scale up their efforts in a coordinated manner, building on their comparative advantage. We will increase our contributions to UNICEF and World Food Programme (WFP) which will help them achieve greater impact and coverage of nutrition interventions and work with the World Bank to ensure that a wide range of sector investments leverage more impact on nutrition. We will also work to deliver a strong set of nutrition results from our European aid.

Support civil society organisations in developing countries to

generate demand and accountability for results.

Address the key weaknesses of the global food system by working

with G8 and G20 partners. New evidence based solutions

We will be achieving our results in nutrition through scaling up programmes where there is evidence of fast and sustainable impact. And we will be working with others to make sure that we fill knowledge gaps and generate new

research on what works and what does not in our drive for value for money. We already have major trials underway in Nepal, Zimbabwe and India looking at a range of interventions and associations with nutrition. This year we have also initiated two major research programme consortia which together will generate evidence, amongst others, on scaling up nutrition-specific interventions in different settings and how to get the best nutrition outcomes from agricultural programmes.

(7)

ACRONYMSANDABBREVIATIONS

Acronyms and abbreviations

CGIAR Consultative Group on International Agriculture Research

CLTS Community Led Total Sanitation

EC European Commission

FAO Food and Agriculture Organisation

EU European Union

GAIN Global Alliance for Improved Nutrition

MDG Millennium Development Goal

NGO Non-Governmental Organisation

REACH Renewed Efforts against Child Hunger

RPC Research Programme Consortium

SAFANSI South Asia Food and Nutrition Security Initiative

SUN Scaling Up Nutrition

UNICEF United Nations Children’s Fund

WFP World Food Programme

WHO World Health Organisation

(8)

Stunted growth

Roshani Parihar, Raman Parihar and Sonam Prajapata line up in Kanpur village in Madhya Pradesh. Three children of the same age show very different development rates – due to the high rates of malnourished children in the area. 6 in 10 children in this area are malnourished.

Photo: Nick Cunard/DFID  

Chapter 1

WHY we are scaling up

nutrition

(9)

WHYWEARESCALINGUP NUTRITION

WHY we are scaling up nutrition

1.1 The scale of the challenge

1. Undernutrition is a major challenge to human and economic development. It

is estimated that almost one billion people globally face hunger1 and are

unable to get enough food to meet their dietary needs. Another one billion people do not get enough vitamins and minerals which, over time, can lead

to complications like blindness2.195 million children under five years of age

are chronically malnourished because of long term exposure to a poor diet

and repeated infections3. More than 1 in 10 children are acutely

malnourished, a life-threatening condition which usually results from a sudden reduction in the diet or severe infection.

2. Children who are undernourished in early childhood are at a much higher

risk of, and less able to recover from infections than healthy children. As a result, they have a much higher risk of early death. Indeed, undernutrition is associated with a third of all child deaths globally. It is estimated that 150 million years of healthy life were lost to poor nutrition in 2004 – five times

that lost to malaria4.

3. The children that do survive hunger and undernutrition have stunted growth

and compromised brain development. A recent multi-country study showed that for every 10% increase in levels of stunting among children, the

proportion of children reaching the final grade of school dropped by almost

8%5. One study in Guatemala demonstrated that improving physical growth

among children under two years of age resulted in a 46% increase in adult

wages when these children grew up6.

4. Many children are born undernourished because their mothers are. Both the

size and age of women at the time of conception as well as nutrition during pregnancy are important. Through this route the disadvantages incurred by poor nutrition are passed between generations.

5. Undernutrition is concentrated in a few countries. The first Millennium

Development Goal (MDG) is to end extreme poverty and hunger (MDG 1). Specifically, it aims to halve the proportion of underweight children in the world by 2015. Globally, the proportion of children under the age of five who

 6         

1. FAO, 2010, The State of Food Insecurity in the World. FAO Rome 2010.

2. Government Office for Science/ Foresight, 2011, The Future of Food and Farming: challenges and choices for global sustainability. London.

3. UNICEF, 2009, Tracking Progress on Child and Maternal Nutrition. UNICEF New York. 4. DFID, 2009, The Neglected Crisis of Undernutrition. Evidence for Action. DFID London. 5. Grantham-McGregor, S. et al (2007), ‘Child Development in Developing Countries:

Developing Potential in the First 5 Years for Children in Developing Countries’, The Lancet, Vol. 369, No. 9555: 60-70.

6. Hoddinott, J., Maluccio, J.A., Behrman, J., Flores, R., and Martorell, R., 2008, Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults Lancet 2008; 371: 411–16.

(10)

WHYWEARESCALINGUP NUTRITION

are underweight declined from 30 to 23 per cent between 1990 and 20097.

58 countries out of 118 are on track to achieve the MDG8. In 40 countries

progress is insufficient, and 20 have made no progress. Most of these are in

sub-Saharan Africa or South Asia9. 80% of stunted children live in 24

countries in sub-Saharan Africa and Asia. More than 45% of children under

five years of age are stunted in 18 countries10.

6. Undernutrition is also concentrated among the poorest. Data from 41

countries show that, on average, stunting levels are almost three times

higher among the poorest households compared with the better off11.

However, stunting is still relatively high among the better off meaning that knowledge, behaviour and other factors also play a part.

7. Undernutrition is complex with many causes. People can become

undernourished either because they do not get enough of the right food to eat and/or they are sick. Illness depresses the appetite and can affect the absorption of nutrients that the body needs to recover and grow. Beyond this, the status of women, childcare practices, access to water and sanitation, access to basic health services and food insecurity all play a

part12.

1.2 Global risks

8. Levels of undernutrition, combined with a growing obesity epidemic are

testimony to the failings of the global food system. But the global food system is facing an additional set of challenges which further threaten whether we can be fed equitably and sustainably in the future.

9. The global population is set to rise to an estimated nine billion by 2050, from

nearly seven billion today. Many people will be wealthier and demanding a high quality diet which is very resource intensive to produce. Yet there are significant threats to food production: increasing competition for land, water and energy and the need to adapt to the consequences of climate change and at the same time reduce green house gas emissions. Globalisation will

continue exposing the food system to new pressures and opportunities13.

10. The UK Government Office for Science’s recent report on The Future of

Food and Farming14 concludes that ensuring that food is affordable by

balancing future food supply and demand, protecting the poor from food

       

7. The Millennium Development Goals Report 2011.

8. http://www.childinfo.org/undernutrition_progress.html accessed on 9th August 2011.

9. http://www.childinfo.org/undernutrition_progress.html accessed on 9th August 2011.

10. UNICEF, 2009, Tracking Progress on Child and Maternal Nutrition. UNICEF New York. 11. Ergo, A., Gwatkin, DR.and Shekar, M., 2009, What difference do the new WHO Child

Growth Standards make for the prevalence and socioeconomic distribution of undernutrition? Food and Nutrition Bulletin, vol. 30, no. 1.

12. DFID, 2009, The Neglected Crisis of Undernutrition. Evidence for Action. DFID London. 13. Government Office for Science/ Foresight, 2011, The Future of Food and Farming:

challenges and choices for global sustainability. London.

14. Government Office for Science/ Foresight, 2011, The Future of Food and Farming: challenges and choices for global sustainability. London.

(11)

WHYWEARESCALINGUP NUTRITION

price volatility and achieving global access to food are key challenges for the future.

11. As the Foresight report states: “The international community must challenge

itself over the apparent ease with which hunger is ignored and ask why

hunger is so easy to neglect”15.

1.3 Global opportunities

12. Undernutrition has been systematically overlooked in setting priorities for

development. A successful response to undernutrition requires a range of policies and programmes across several sectors: collective action bound by a common goal. Nutrition is the business of neither the health sector nor the agriculture sector: it is the responsibility of both but also involves tackling poverty, gender inequality, improving trade and markets, budget allocation and planning and much more besides. If the world acts now we can

dramatically reduce under-nutrition over a short time period.

13. First, we know what works. The science is clear that the first 1,000 days

after conception are the most important. Intervening within this period will have life-long and life-changing impacts on educational attainment, labour capacity, reproductive health and adult earnings. If we wait until a child is

two years old, the effects of undernutrition are already irreversible16.

14. Second, there is now a policy consensus on how the nutrition challenge

should be tackled. This is enshrined in a new global movement; Scaling Up Nutrition (SUN), launched in September 2010 with the backing of global leaders, including the UK Secretary of State for International Development, who committed to give 1,000 days of strong political momentum to scale up nutrition interventions in the first 1,000 days of a child’s life. SUN is poised to overturn the years of neglect, galvanise greater leadership, align partners behind key principles for action and incentivize coordination and delivery of results.

15. Third, success stories are leading the way for others. Countries which have

taken concerted action to reduce undernutrition have shown remarkably fast

rates of reduction. Brazil, Peru, Thailand and China are among these17. This

shows what can be done with the right policies and programmes in place. Through SUN, these countries can influence and support others to do the same.

 8         

15. Government Office for Science/Foresight, 2011, The Future of Food and Farming: challenges and choices for global sustainability. London.

16. Victora CG, et al, for the Maternal and Child Undernutrition Study Group 2008, Maternal and child undernutrition: consequences for adult health and human capital. Article 2, Lancet 371, 340-57.

17. Monteiro et al, 2010, Narrowing socio-economic inequality in child stunting: the Brazilian experience, 1974-2007. Bulletin of the World Health Organisation 88:305-311 and Acosta MA, 2011, Analysing Success in the Fight Against Malnutrition. IDS Working Paper Vol 2011 No 367.

(12)

WHYWEARESCALINGUP NUTRITION

Responding to undernutrition in Bangladesh

   

Why we are scaling up

Over the past two decades, Bangladesh has experienced sustained economic growth and a reduction in poverty rates from 40% in 2005 to 31.5% in 2010. Bangladesh is now on track to achieve Millennium Development Goals on both child mortality and improving maternal health. Despite this progress, undernutrition remains the major development challenge. For example, 43% of children under five years of age are stunted; 30% of women of reproductive age are chronically

undernourished; and 87% of children under two years of age are anaemic.

How we will work

DFID is tackling undernutrition in Bangladesh through two main channels and with a focus on pregnant and breastfeeding women, adolescent girls and children under five years of age. First, DFID is working through the Government of Bangladesh’s health sector to incorporate nutrition specific interventions into all primary health care services, and establish 3,000 additional community clinics to aid delivery. A national nutrition service plan is in place with both a budget and management system. Second, DFID is looking at options to sharpen nutrition outcomes from existing programmes. Specifically we are committed to integrating direct nutrition interventions in to our extreme poverty programmes, to ensure that a better income is matched with a better diet and nutritional status. We also continue to raise nutrition considerations with partners in the major development forums, push more broadly on policy options for social protection and food security and provide support to the donor convenor for the Scaling Up Nutrition (SUN) movement in Bangladesh.

What results we will deliver

Through our livelihoods programmes, DFID’s support will reach over two million people with a combination of asset and cash transfers and skills training to improve household income and access to food. In addition, DFID will provide one to one nutrition counselling to 103,500 pregnant and breastfeeding women and

micronutrient supplements and de-worming to 225,000 children under five and 243,000 adolescent girls. Combined this is expected to improve infant and young child feeding practices such as exclusive breastfeeding, the quality and quantity of complementary foods and promote good hygiene. This will reduce micronutrient deficiencies, especially anaemia, underweight and stunting.

Through support to the health sector from2011–2015, DFID will reach375,000 children under five years of age every year with vitamin A, de-worming and nutrition counselling for their mothers and 50,000 pregnant women with iron tablets and nutrition counselling.

 

(13)

  10   

Child upper arm circumference measurement, Nigeria

Photo: Jane Miller/DFID

Chapter 2

(14)

HOWWEWILLWORK

HOW we will work

2.1 Working in partnership

16. The scale of the nutrition challenge needs collective action. Governments,

international organisations, civil society organisations and the private sector have a major role to play in ensuring that support is sufficient, well

coordinated, aligned and timely. The UK works with other donors, building on our comparative advantage, ensuring complementarity and avoiding duplication. We align our support behind national plans and reporting frameworks of developing country governments and use our support to promote stronger involvement from civil society and the private sector.

17. The Scaling Up Nutrition (SUN) movement is bringing together all these

actors behind a common vision for tackling undernutrition in partnership in those countries most affected. The UK supports SUN with technical and financial assistance and uses its influence to encourage more partners to be involved in the SUN movement.

18. The SUN Framework for Action promotes a twin track approach to

undernutrition: nutrition-specific interventions and nutrition-sensitive development (described below). Economic growth can play a role in

improving nutrition, but on its own, is not enough. Countries that have rapidly reduced undernutrition have experienced good economic growth but have also adopted deliberate policies and programmes to improve the diet and health status of pregnant women and young children, particularly in the poorest groups. The UK adopts this approach to scaling up. Figure 1 shows the determinants of undernutrition, and illustrates how nutrition-specific interventions and nutrition-sensitive development address these

determinants.

2.2 Tackling the immediate causes

19. Nutrition-specific interventions, which address the immediate causes of

undernutrition, have been proven to deliver among the best value for money of all development interventions. Vitamin A and zinc supplementation, salt iodisation and crop bio-fortification have been ranked among the top five

best development buys18.

20. The Lancet series on Maternal and Child Undernutrition19 also showed that

13 proven nutrition interventions, if delivered at scale, could together reduce stunting by one third globally. These include interventions such as

preventing and treating vitamin and mineral deficiency through

supplementation and fortification, supporting exclusive breastfeeding,

       

18. Behrman, JR; Alderman, H and Hoddinott, J, 2004, Copenhagen Consensus – challenges and opportunities: Hunger and malnutrition.

19. Bhutta, Z.A, et al, 2008, What works? Interventions for maternal and child undernutrition and survival, The Lancet, Vol 371, Issue 9610, Pages 417-440

(15)

HOWWEWILLWORK

behaviour change communication for young child feeding, treatment for severe acute undernutrition, and treatment of infections. They have been

shown to yield a benefit to cost ratio of 15.8 to 120.

21. While the evidence for impact of these interventions is clear, less is known

about how to deliver them at scale and which channels are the most cost effective. Countries that have successfully scaled up nutrition interventions show the importance of having a functioning health system with effective

supply chains and a cadre of community based health workers21.

2.3 Addressing the underlying causes

22. While deficiencies in some nutrients are known to be specifically linked to a

failure to grow, children need to absorb sufficient energy, protein and fat as well as multiple micronutrients to grow properly. Unless all the limiting conditions can be addressed, childhood growth will be insufficient.

Furthermore nutrition-specific interventions delivered successfully at scale will only reduce stunting by one third. This means that the solutions to undernutrition must go beyond the provision of specific nutrients (see Figure 1).

Figure 1

       

20. Scaling Up Nutrition Roadmap. September 2010.

  12 

21. UN Standing Committee on Nutrition. 2011, Sixth Report on the World Nutrition Situation. WHO. Geneva

(16)

HOWWEWILLWORK

It requires that:

 diets are sufficient in their entirety (with implications for poverty alleviation and agriculture programmes);

 children are not experiencing infections which compromise their appetite or reduce their absorption of nutrients (with implications for health

services and environmental health programmes); and

 those responsible for caring for young children, usually women, are sufficiently empowered to do so (with implications for women’s empowerment and education programmes).

23. Nutrition sensitive development involves adjusting and re-designing

programmes across a range of sectors which have potential to address the underlying causes of undernutrition, to ensure that they deliver results for nutrition. These programmes represent a huge untapped potential for reducing undernutrition and may hold the key to the remaining two thirds of stunting not met with nutrition specific interventions. The evidence

challenge for these nutrition sensitive programmes is greater than for the nutrition specific interventions because these programmes have long causal chains, and different contexts can influence the outcome. The evidence for programmes which offer the greatest scope to improve nutrition includes:

 Agriculture  Health

 Cash transfers

 Gender empowerment

 Water, sanitation and hygiene promotion. Agriculture

24. 75% of the world’s poor live in rural areas of which 86% rely on agriculture to

survive22. 43% of the world’s agricultural labour force is women23.

Agriculture has the potential to drive improved nutritional outcomes in many ways. It provides a source of food and nutrients, a source of income, has effects on food prices, affects the environment in which people live and influences women‘s time for taking care of very young children and their power in decision making.

25. Several studies show that a 10% increase in income per capita usually

results in a 3-4% decline in stunting24. But if growth is in the agriculture

sector, and concentrated amongst the rural poor, we see a faster reduction

in stunting25. This relationship is even stronger in food insecure contexts26.

       

22. World Bank, 2008, Agriculture and Poverty Reduction policy Brief based on World Development Report 2008, Agriculture for Development. World Bank, Washington. 23. FAO, 2010, The State of Food Insecurity in the World. FAO Rome.

24. Webb P and Block S, 2010. Support for agriculture during economic transformation: Impacts on poverty and undernutrition. Proceedings of the National Academy of Sciences of the United States of America

25. Webb and Headey, D, 2011, Turning Economic growth into nutrition sensitive growth 2020 Conference Paper 6. IFPRI.

(17)

HOWWEWILLWORK

 

While we know agricultural growth is important for reducing stunting at the aggregate level, the evidence for showing the impact of agricultural

programmes on nutrition is weaker. DFID’s systematic review27 of the

nutritional impact of agriculture interventions concluded that agricultural interventions improve the production and consumption of nutritious food among poor households but could not identify a direct impact on the

nutritional status of children because most studies were too small to detect an impact.

Health

26. As the health sector provides the main delivery channel for nutrition specific

interventions, efforts to improve health systems are very important. This requires support for the right national policy mix, a trained and appropriate workforce; national health information systems; safe, effective and

affordable essential medicines and diagnostics; and improved management of health services.

27. The health sector also has a crucial role in addressing the ill health that

contributes to undernutrition. Specifically, malaria frequently causes iron deficiency and anaemia; measles and diarrheal infections increase the body‘s vitamin A requirements and can trigger severe forms of deficiency such as blindness. Parasitic infections, particularly hookworm, cause iron deficiency and anaemia; and HIV compromises the nutritional status of infected individuals. In turn, undernutrition worsens the effects of the disease. Disease control interventions are estimated to contribute to a 3%

reduction in stunting28.

Cash transfers

28. The evidence for the impact of cash transfers on undernutrition is mixed.

Conditional cash transfer programmes in Latin America showed positive outcomes for nutrition in Mexico, Nicaragua, and Colombia and there is also evidence of the impact of unconditional cash transfers on nutritional status from South Africa. However there are also some programmes where little or

no impact was found29.

29. Reasons for the size and direction of impact are still being investigated. A

Save the Children review concludes that cash transfers have their greatest impact on reducing child mortality when programmes prioritise children

under five years old and pregnant women, provide access to complementary

  14        

26. Webb P and Block S, 2010. Support for agriculture during economic transformation: Impacts on poverty and undernutrition. Proceedings of the National Academy of Sciences of the United States of America

27. Masset E et al, 2011, What is the impact of interventions to increase agricultural production on children’s nutritional status? A systematic review of interventions aiming at increasing income and improving the diet of the rural poor. Unpublished.

28. Bhutta, Z.A, et al, 2008, What works? Interventions for maternal and child undernutrition and survival, The Lancet, Vol 371, Issue 9610, Pages 417-440

29. Mylene Lagarde, Andy Haines, Natasha Palmer, 2009, Conditional Cash Transfers for Improving Uptake of Health Interventions in Low- and Middle-Income Countries: A Systematic Review The Journal of the American Medical Association.

(18)

       HOWWEWILLWORK

services and by making transfers sufficiently generous30. Communication

with beneficiaries is also important. For example, it is thought that the negative impact found in Brazil was due to mothers thinking children would be excluded from the programme if they started to grow normally.

Gender empowerment

30. Women are usually the primary care givers for young children while also

being productive members of the household. The status of women is strongly associated with nutritional outcomes. One study estimated that women’s education was responsible for almost 43% of the total reduction in undernutrition across 63 countries between 1971 and 1995. This study also suggested that improving the status of women in South Asia would reduce the level of underweight children under three years of age by approximately

12% and in sub-Saharan Africa by nearly 3%31.

Water, sanitation and hygiene promotion

31. There is some evidence of an association between access to improved

sanitation and stunting. One multi-country study showed that improved sanitation is associated with a reduction in height deficit, ranging from

22-53% for urban children and from 4-37% for rural children32. For water supply

the effects were much smaller. Hygiene interventions (including hand washing, water quality treatment, sanitation, and health education) have been estimated to contribute to a 2-3% reduction in stunting, but the modelling was based on their impact on diarrhoea prevalence and the link between diarrhoea and stunting. There are some hypotheses which suggest

that improved sanitation may improve growth through other mechanisms33.

As in other sectors there is limited evidence on the impact of sanitation interventions on child growth.

2.4 Strengthening monitoring and evaluation

32. We will track progress in levels of underweight among children under five as

a key indicator of development progress. We will also monitor the number of children under five years of age reached through DFID supported nutrition-related programmes as a headline DFID results indicator. Progress against these indicators will be published annually. Progress in delivering individual programmes will be tracked using a range of indicators.

33. DFID will embed evaluation throughout its portfolio of nutrition-related

programmes. The results of these evaluations will enable DFID and partners to identify the most effective nutrition interventions for future

 

30. Yablonski, J. and O’Donnell, M., 2009, Lasting benefits: the role of cash transfers in tacking child mortality. Save the Children Fund; London.

31. L. Smith, U. Ramakrishnan,A. Ndiaye, L. Haddad, and R. Martorell, The Importance of Women’s Status for Child Nutrition in Developing Countries,Research Report 131, IFPRI, 2003.

32. Esrey, S, 1996, Water, waste and well being: a multi country study American Journal of Epidemiology Vol 143 no 6

33. Humphrey J, 2009, Child undernutrition, tropical enteropathy, toilets, andHandwashing Lancet 2009; 374: 1032–35.

(19)

HOWWEWILLWORK

 

programmes. In order to achieve this, we will establish a Technical Advisory Group which will involve global experts providing specialist expertise on the design and implementation of our evaluations and to ensure that they generate evidence which addresses critical gaps in knowledge.

34. We will also support our partners to embed nutrition evaluation. In particular

we will support the World Bank’s Strategic Impact Evaluation Fund to generate robust evidence on nutritional impact from the World Bank’s large scale agriculture, food security, health, safety net, poverty reduction, early childhood development and environmental health programmes. We will also increase our support to evaluation of innovative nutrition projects

implemented by civil society organisations to capture the lessons and to allow more robust methods and academic partnerships to be pursued.

35. Overall, these activities will place high-quality impact evaluation at the centre

of DFID's nutrition programmes, and will encourage and support other organisations to do the same. In turn, they will improve our knowledge of how to intervene most effectively to address undernutrition, and will enhance accountability by allowing the results of nutrition-related investments to be determined and communicated.

2.5 Building the evidence base

36. We know that high levels of coverage of nutrition-specific interventions can

reduce stunting by one third and address a quarter of child deaths. But the evidence on how to achieve high levels of coverage and address the remaining two thirds of the problem is weaker. There are also significant evidence gaps on the best approaches to tackling adolescent and maternal undernutrition.

37. We will place considerable priority on building the evidence base through

research, and coordinating with others on their research investments, to ensure that there is a much larger body of high quality evidence available by 2015 to inform future programmes.

2.6 Building our skills and capacity

38. Our significant scale up of programmes to improve nutrition means we need

to strengthen our capacity to design effective nutrition-related programmes within our humanitarian, health, livelihoods and social development

professional cadres. To do this we are supporting the London School of Hygiene and Tropical Medicine to develop a Distance Learning Course on multi-sectoral nutrition programming, which will be publicly available. We will also build multi-year partnerships with expert organisations to maximise the quality and effectiveness of our investment.

(20)

HOWWEWILLWORK

Scaling up nutrition: Nigeria

Why we are scaling up

Despite its middle income country status, one million children under five years of age die every year in Nigeria, and about 35% of these preventable deaths are due to undernutrition. Undernutrition is concentrated in northern States where access to health services is especially low. Here, 50% of all children under five years of age are stunted, 20% suffer from acute malnutrition, and fewer than 10% of women give birth at a health facility.

How we will work

DFID Nigeria is supporting Federal, State and Local government to integrate undernutrition into the health services and improve government budgeting and expenditure for nutrition. The programme will deliver:

 Improved prevention and treatment of undernutrition in Primary Health Care

 Government support to improve leadership on nutrition

 Improved evidence base on the structural barriers and determinants of undernutrition in the Northern Nigeria context.

By taking a proactive and preventative approach and working in partnership with government, we hope to apply this knowledge to identify and build resilience to future shocks.

What results we will deliver

Through a combination of improved infant and young feeding practices (such as exclusive breastfeeding and complementary feeding), and micronutrient supplementation including vitamin A and de-worming, DFID will improve the nutritional status of 6.2 million children under the age of five and pregnant women in northern Nigeria. Also 140,000 children with severe acute malnutrition will have received timely support through the community management of acute malnutrition preventing the need for costly and ineffective late interventions. Through our support to state capacity and nutrition monitoring we will substantially support the development of a strong system to prevent and treat malnutrition in areas where the need is greatest.

(21)

  18 

Providing clean water and sanitation

Children in Sindh, Pakistan, play at a water pump in a village. Photo: Russell Watkins/DFID

 

Chapter 3

WHAT results we will

deliver

(22)

WHAT RESULTS WE WILL DELIVER

WHAT results we will deliver

39. We are seeking dramatic reductions in levels of undernutrition. Overall the

UK’s aid programme will reach 20 million children under five years of age during the period 2011–2015, in addition to those we will reach through humanitarian response. We will do this through:

 Reaching more adolescent girls, pregnant women and children under five years of age with nutrition specific interventions

 Delivering greater impact from nutrition-sensitive programmes  Building a more effective international response to undernutrition  Identifying new solutions to undernutrition on the basis of what works.

Reduction in undernutrition

Greater nutritional 

impact  from  nutrition‐

sensitive  interventions 

Greater coverage of 

nutrition‐specific  

interventions 

  New solutions to 

undernutrition 

More effective international response

 to undernutrition 

% reduction in 

underweight  

among  

children  

under five years

Number of children under  five reached   with nutrition‐ 

specific and   nutrition‐ 

sensitive   programmes 

Figure 2

3.1 Reaching more adolescent girls, pregnant women and

children under five years of age with nutrition specific

interventions

40. We will build on our comparative advantage in health where we are already

significantly scaling up our programmes to save the lives of at least 50,000 women during pregnancy and childbirth and 250,000 newborn babies by 2015 and to dramatically reduce deaths from malaria. We are using a combination of targeted, disease specific interventions, global level engagement and dialogue, supporting improvements to health systems, including support to human resources for health, domestic health financing arrangements and access to medicines. These programmes provide an

(23)

WHAT RESULTS WE WILL DELIVER

excellent platform for scaling up our support to nutrition specific

interventions, and we will also go beyond these programmes to explore new delivery channels. For example:

 In five states in Northern Nigeria we will reach 6.2 million children

through the scale up of community management of acute undernutrition, micronutrient supplementation, routine services and child health weeks.  In India we will focus our support in three of the poorest Indian states

(Bihar, Madhya Pradesh and Orissa) which are home to 13 million stunted children. We aim to reach an additional 3.9 million children with nutrition specific interventions over the next four years and will support a behaviour change communication campaign focused on promoting good child feeding. Resources will be invested in health, nutrition, water and sanitation services to ensure that undernourished children and their families get all the services they need to make them grow well and be healthy.

 In Bangladesh we support a multi-donor funded health sector programme which delivers scaled-up nutrition specific interventions in all primary health care services. From 2011–15, our funding will reach 375,000 children under five years of age with vitamin A, deworming and nutrition counselling each year; and 50,000 pregnant women with iron tablets and nutrition counselling.

 In Tanzania we are planning to support the national fortification

programme to fortify the majority of wheat and maize flour and edible oil produced commercially by approved manufacturers. We

will also support a pilot to investigate how best to improve nutritional outcomes for those who are not reached by National Food

Fortification: people living in rural areas; the very poorest; and children aged 6-24 months. The pilot is under design; options we are considering are working with small scale rural millers and providing a range of

additional food fortificants for children.

41. We will continue our strong track record in humanitarian response –acting

swiftly to save lives on the ground, while playing a leadership role in

reforming the international humanitarian system34. As a result of our recent

Humanitarian Emergency Response Review, we will be going further to ensure we help build people’s resilience and capacity to withstand shocks like drought. Tackling acute undernutrition will remain a strong focus of our humanitarian response and where possible we will use these programmes to build longer term capacity to respond to nutritional crises through multi-year funding and to strengthen the impact of our programmes on preventing alarming levels of acute undernutrition, especially in fragile states.

  20         

(24)

WHAT RESULTS WE WILL DELIVER

3.2 Delivering greater impact from nutrition sensitive

programmes

42. The UK is one of the largest supporters of programmes that give the poorest

and most vulnerable people cash and we will build on this experience to deliver greater nutritional impact as we plan to scale up our support to these programmes over the next five years. The UK is also committed to putting girls and women at the centre of our development assistance since we know that the benefits of investing in girls and women are transformational – for their own lives and for their families, communities, societies and

economies35. These combined priorities provide an excellent foundation for

nutrition-sensitive programming and we will design programmes which aim to maximise nutrition results. For example:

 In Bangladesh we will strengthen the nutritional impact of our existing extreme poverty programmes (Economic Empowerment of the Extreme Poor Programme, Chars Livelihood Programme, and Urban Partnership for Poverty Reduction) by integrating the delivery of nutrition specific interventions (including de-worming and home fortification) reaching 243,000 adolescent girls, 103,500 pregnant women and 225,000 children under five years of age. This will enhance the nutritional impact of the livelihood interventions that include asset transfers, cash transfers, training, water and sanitation support and income generation.

 In Zambia we are providing 10 years of support to the government’s child grant programme aimed at addressing the economic barriers to good nutrition for children under five years of age. Focused in five districts which have the highest rates of extreme poverty and under five mortality, the first phase of this programme will test programme impacts on

stunting to inform future scale-up.

 In Bihar (India) we will pilot cash transfers with and without conditions for maternal and child nutrition improvements. This will significantly add to the national and international knowledge on the impact of cash transfers as India scales up a national nutrition cash transfer.

43. We will also go beyond cash transfers to leverage greater nutritional impact

from our programmes. For example:

 In the South Asia region in 2010 we launched the South Asia Food And Nutrition Security Initiative (SAFANSI) with the World Bank. SAFANSI’s objective is to increase the commitment of governments in the region and development partners to more effective and integrated food and nutrition-related policies and investments. It focuses on six countries and is aimed at addressing the ‘South Asian Enigma’ - how chronic undernutrition remains intractable despite high economic growth. SAFANSI promotes multi-sectoral actions for measurable improvements in food and nutrition security.

       

(25)

WHAT RESULTS WE WILL DELIVER

 In Zambia, DFID plans to support the expansion of evidence based and innovative nutrition interventions that address some of the most prevalent micronutrient deficiencies such as vitamin A and zinc. This may

include additional preparatory work needed for introducing biofortified staple crops, including efficacy trials.

 In Malawi the UK is also supporting nutrition indirectly through support to agriculture. This includes providing 350,000 farmers with affordable legume seed (helping to diversify farmers diets and incomes), and providing at least 6-10,000 urban poor households with low cost milk through a pilot dairy marketing project.

 In Bihar state in India we have begun a pilot to test an approach to getting collective community action to adopt better sanitation practices (Community Led Total Sanitation). CLTS has already proved to be very effective in other (wealthier) States of India and if the Bihar pilot is successful it will be scaled up across the state. We have also begun work to improve the ability of frontline health and nutrition workers to integrate core hygiene-related health activities in their day-to-day work. Our Bihar partnership will also ensure that basic water and sanitation

facilities are provided in all new Anganwadi centres36 and clinics. We are

exploring similar partnerships with the government in Orissa and Madhya Pradesh.

3.3 Building a more effective international response to

undernutrition

44. A more effective collective response to undernutritrion is desperately

needed. Our vision is for an international response which:

 Responds to country priorities.

 Supports the delivery of results at a much greater scale through

partnering with the private sector; and through our investments in multilateral institutions.

 Sustains political engagement in this neglected issue.

 Addresses the key weaknesses of the global food system.

Responding to country priorities

45. DFID actively supports the Scaling Up Nutrition movement. This aims to

improve the coordination, coherence and scale of the response to

undernutrition globally. The movement involves almost 20 countries that are committed to scaling up nutrition by developing national multi-sectoral plans and responses, behind which donors align. DFID helps convene the donors in Zambia and Nepal and is actively involved in supporting the government to scale up in Bangladesh, Mozambique, Tanzania, Uganda and Zimbabwe.

  22         

36. Anganwadi centres are where the Integrated Child Development Scheme services are delivered. This is a national programme in India aimed at improving the health and development of young children.

(26)

WHAT RESULTS WE WILL DELIVER

Supporting the delivery of results at a much greater scale

46. We believe the private sector has a much greater role to play in tackling

undernutrition through the food they produce, their ability to reach people in remote areas and their communications, marketing and distribution capacity.

47. The UK is committed to finding better ways of realising the potential of the

private sector to address undernutrition and reduce the risks of overnutrition. For example:

 This year we begin a multi-year partnership with the Global Alliance for

Improved Nutrition (GAIN). GAIN has a strong track record in bringing together the private and public sectors to drive nutrition solutions.

Through our partnership with them, GAIN will reach more than 60 million people with fortified foods.

 In Zambia we are exploring a range of strategies to increase the supply

and demand of micronutrients. Public-private partnerships are likely to form a core element of the programme, building alliances between famer groups, government agencies, donors, the private sector and NGOs. We may also support innovative ways to expand the provision of oral

rehydration sachets and zinc supplements for the treatment of acute diarrhoea in rural areas by using Coca Cola distribution channels.

48. We will support the multi-lateral agencies which have a role to play in

tackling undernutrition to scale up their efforts in a coordinated manner, building on their comparative advantage. Our increases in funding will be directly linked to agency performance based on our independently verified Multilateral Aid Review. For example:

 We will increase our voluntary contributions to UNICEF since it is an important partner in achieving many of our development objectives. This will support UNICEF in delivering its commitment to scale up and sustain coverage of its high-impact nutrition interventions in the programme areas of: infant and young child feeding; micronutrients; nutrition security in emergencies; and nutrition and HIV and AIDS. We will also continue to work with UNICEF to improve its performance in humanitarian

emergencies and protracted crises and to strengthen its reporting of results at the organisational level.

 We will increase our support to the World Food Programme (WFP) to build its capacity on nutrition. WFP prevents and treats moderate acute undernutrition in emergency settings and where seasonal levels become unacceptably high. Our support will help them significantly increase the coverage of treatment. We will also work with WFP to help define their role in preventing stunting in high burden countries.

 The UK is working with the Food and Agriculture Organisation (FAO) to improve its overall performance and delivery of results, especially at country level. FAO monitors hunger globally and assists countries to address food and nutrition security through policy advice, capacity building and support to field interventions.

(27)

WHAT RESULTS WE WILL DELIVER

 The UK will continue to support the World Health Organisation to provide normative standards and frameworks to support governments to tackle undernutrition.

 The UK will continue to support the World Health Organisation to provide normative standards and frameworks to support governments to tackle undernutrition.

 REACH (Renewed Efforts against Child Hunger) is the joint United Nations initiative to address MDG 1. The UK is working with the REACH partner agencies to improve their performance and delivery of results, including effective partnerships. REACH is potentially well positioned to provide collective and coordinated UN support to the scale-up effort in response to country demand.

 REACH (Renewed Efforts against Child Hunger) is the joint United Nations initiative to address MDG 1. The UK is working with the REACH partner agencies to improve their performance and delivery of results, including effective partnerships. REACH is potentially well positioned to provide collective and coordinated UN support to the scale-up effort in response to country demand.

49. The World Bank has a crucial role to play in tackling undernutrition, given

the scale of its programmes across a range of sectors. Over the next three years UK support to the International Development Association will help 650,000 people access a basic package of health, nutrition, or population services. We will work with the World Bank to ensure that its investments in agriculture, poverty alleviation, health and social protection deliver the greater impact on nutrition.

49. The World Bank has a crucial role to play in tackling undernutrition, given

the scale of its programmes across a range of sectors. Over the next three years UK support to the International Development Association will help 650,000 people access a basic package of health, nutrition, or population services. We will work with the World Bank to ensure that its investments in agriculture, poverty alleviation, health and social protection deliver the greater impact on nutrition.

50. The European Commission (EC) has a critical role to play in tackling

undernutrition particularly through its investments in agriculture, food

security, social protection and health. We will work to deliver a strong set of nutrition results from our European aid. We have worked closely with the EC in developing programme guidance on multi-sectoral approaches to

undernutrition.

50. The European Commission (EC) has a critical role to play in tackling

undernutrition particularly through its investments in agriculture, food

security, social protection and health. We will work to deliver a strong set of nutrition results from our European aid. We have worked closely with the EC in developing programme guidance on multi-sectoral approaches to

undernutrition.

Sustaining political engagement Sustaining political engagement

51. Given the extent to which nutrition has been neglected, and the importance

of ensuring the scale up effort is well coordinated and focused on results the UK places considerable priority on ensuring that political leadership for nutrition is increased and sustained. Furthermore, countries which have had a high burden and have successfully reduced levels of undernutrition, have always done so with strong leadership at the top of government, mobilising resources from multiple sectors and stakeholders to tackle a common goal. Where our partners have neglected the problem, we will press for stronger commitments and work to ensure greater political leadership for nutrition. For example:

51. Given the extent to which nutrition has been neglected, and the importance

of ensuring the scale up effort is well coordinated and focused on results the UK places considerable priority on ensuring that political leadership for nutrition is increased and sustained. Furthermore, countries which have had a high burden and have successfully reduced levels of undernutrition, have always done so with strong leadership at the top of government, mobilising resources from multiple sectors and stakeholders to tackle a common goal. Where our partners have neglected the problem, we will press for stronger commitments and work to ensure greater political leadership for nutrition. For example:

 We will scale up our support to civil society organisations in developing countries that play a critical role in helping to generate demand for improved nutrition at country level and driving government accountability for results.

 We will scale up our support to civil society organisations in developing countries that play a critical role in helping to generate demand for improved nutrition at country level and driving government accountability for results.

 DFID will work to ensure that a leadership structure for SUN is quickly established which involves all stakeholders, including civil society and the private sector and which can help to galvanise greater commitments to reduce undernutrition, and provide a forum for reviewing progress.  DFID will work to ensure that a leadership structure for SUN is quickly

established which involves all stakeholders, including civil society and the private sector and which can help to galvanise greater commitments to reduce undernutrition, and provide a forum for reviewing progress.

(28)

WHAT RESULTS WE WILL DELIVER

Addressing the key weaknesses of the global food system

52. Building on the recommendations of the Foresight report37, we are working

with others to address some of the wider challenges in the global food system. Specifically:

 The UK has worked with partners in the G8 and the G20 to improve food security for poor people in developing countries in the wake of the food price crisis of 2008. As a contributor to the Aquila Food Security

Initiative, established at the G8 Summit in 2009, the UK committed funds (£1.1 billion between 2009 and 2012) to improve food and nutritional security in line with agreed aid effectiveness principles. These include investing in country-owned plans, fostering strategic coordination at national, regional and global level in order to reduce duplication of effort and improve governance, and ensuring a strong role for the multilateral system in improving efficiency and responsiveness of the global food system.

 The UK also supports action proposed by G20 countries to tackle the impact of food price volatility. This year, G20 Ministers of Agriculture have committed to:

 Improving agricultural production and productivity, in response to

a growing demand for agricultural commodities;

 Increasing the flow of information on grain harvest and stock

levels so that global food markets function more effectively;

 Strengthening international policy coordination in order to enhance

confidence in international markets and to enable the global food system to respond more coherently and efficiently to food crises; and

 Developing better risk management tools for governments, firms

and farmers and helping build capacity to manage and mitigate the risks associated with food price volatility, in particular in the poorest countries.

3.4

Identifying new solutions to undernutrition on the basis of

what works

53. DFID has already made considerable investments in nutrition-related

research to date. We will build on these programmes, and scale up our investments in research to ensure the delivery of new approaches to tackling undernutrition, and a significant body of high quality evidence on what works and what doesn’t is made available to decision makers.

54. We are investing in a series of systematic reviews to synthesise data on key

areas of nutrition programming. By working with other donors, such as the Gates Foundation and World Health Organisation, we will ensure that key

       

37. Government Office for Science/ Foresight, 2011, The Future of Food and Farming: challenges and choices for global sustainability. London.

(29)

WHAT RESULTS WE WILL DELIVER

evidence gaps are addressed. DFID is specifically focusing on systematic reviews of the impact of nutrition-sensitive programmes. We will use the findings to inform programmes, to inform programme guidance being developed by the World Bank and to inform evaluation priorities.

55. We are supporting a series of large trials to rigorously test the impact of

specific interventions. For example:

 In Nepal we will be testing the impact of combinations of cash transfers, food transfers and nutritional counselling on low birth weight and then testing the most effective intervention under normal operating conditions to ensure policy relevance.

 In Zimbabwe we are supporting a large trial to test the impact of

improved sanitation on nutritional status and specifically investigating the

role of tropical enteropathy38 in inhibiting child growth.

 In Madhya Pradesh, in India, we are supporting research to test community based treatment of severe acute malnutrition.

 In Orissa, in India, we will support a randomised control trial to address a current evidence gap on what is the proportional impact of clean water and toilet provision on child health and nutrition.

56. This year we have initiated two major research programme consortia (RPC),

each providing funding over six years. The first, Transform Nutrition, which will be led by the International Food Policy Research Institute, will address key research questions relating to the challenges of scaling up nutrition-specific interventions in different settings, the effectiveness of nutrition sensitive interventions, and the promotion of enabling environments.

57. We intend to launch the second RPC, which focuses on South Asia in late

2011. It will ensure that high quality evidence is generated on the linkages between agricultural policies, investments and nutrition outcomes, and on effective actions for making agriculture more pro-nutrition. The programme will ensure that this evidence base is used by policy makers and

practitioners in Afghanistan, Bangladesh, India and Pakistan to accelerate nutrition security.

58. The UK has major investments in agricultural research. Understanding the

links between evidence-based agricultural interventions and nutritional outcomes is an important and expanding area of DFID research. We will appoint a new Senior Research Fellow who will provide expert guidance. We will undertake a research mapping exercise in agriculture and nutrition, with other donors, in order to determine research gaps and potential additional areas of research investment.

59. We will build on our substantial investment in the Consultative Group on

International Agricultural Research (CGIAR) to ensure that, in collaboration with other major funders, the key evidence gaps on how to maximise the

  26         

(30)

WHAT RESULTS WE WILL DELIVER

impact of agriculture on nutrition are addressed. The CGIAR is about to launch a new Consortium Research Programme on Agriculture for Improved Health and Nutrition, which includes the continued development and roll out of biofortified crops. In addition:

 We are in detailed discussion with the Bill and Melinda Gates Foundation on support to the Abdul Latif Jameel Poverty Action Lab to initiate a programme of randomised evaluations to test the impact of agriculture technologies on nutrition.

 We are working closely with other partners to develop a multi-donor funded initiative to pilot agriculture “pull mechanisms”. This will include specific pilots that address market failures in the nutrition sector through results based funding.

 We are in discussion with partners on support to the Programme for

Aflatoxin Control in Africa39 to study whether, and quantify to what extent,

aflatoxin consumption leads to childhood stunting.

Conclusion

60. These results, when combined with the efforts of others operating at local,

national, regional and global levels have the potential to make a dramatic impact undernutrition. Our vision is that by 2015:

 The high impact low cost nutrition interventions will be accessible to millions more adolescent girls, pregnant women and young children.  Investments in a range of sectors will be delivering much greater

reductions in undernutrition, and measuring and documenting these impacts.

 The international response is responsive to country demands, better streamlined and coordinated and with a strong track record in galvanising greater political support for tackling undernutrition and delivering results on the ground.

 We will have a much greater understanding of the investments which must be prioritised in future based on a greatly increased evidence base of what works.

Together, if we act fast, we can get the first Millennium Development Goal back on track.

       

39. Aflatoxin is a toxic substance produced by fungi (such as Aspergillus flavus), that are abundant in agricultural soils. Aflatoxins contaminate maize, groundnuts as well as other crops. Chronic exposure to aflatoxins is implicated in aflatoxicosis (which can result in immediate death from liver failure), stunting and kwashiorkor in children, the bioavailability of micronutrients, immunodeficiency and immuno-suppression, liver cancer, liver disease and a similar range of health problems in animals that consume contaminated feed.

(31)

WHAT RESULTS WE WILL DELIVER

Why we are scaling up – helping economic growth deliver for nutrition

India is growing fast and making good progress in tackling poverty. But India is off track to achieve the MDG hunger target and has 40% of the world’s underweight children. In the poorer states where DFID works, half of all children are stunted. It’s a complex problem with many causes: women’s weaker status in education and the household; lack of clean water and use of toilets; limited choice of family planning and inadequate diets. A third of all Indian women are underweight, and over half are anaemic which means that nearly a third of all children are born

undernourished.

The Government of India recognises these challenges and is addressing them. Public spending on health has doubled since 2004 (from £5 billion to around £11 billion in 2008–09). India’s Integrated Child Development Scheme (ICDS) - the world’s largest nutrition scheme - delivers food to pregnant mothers and infants. ICDS is sharpening its focus on nutrition in the first 1,000 days of pregnancy and a child’s life (the critical period for preventing physical and brain damage caused by malnutrition). A cash payment is being launched to support new mothers who breastfeed and immunise their children. Mothers are getting more advice on weaning their children healthily.

How we will work – putting women and girls at the heart of our work nutrition

By working in an integrated way that puts women and girls at the heart of our work, DFID can help make a big difference in nutrition. Working in partnership with the Government of India, state governments in the poorer states, UNICEF, NGOs and community groups, DFID can help poor women and girls get quality healthcare, nutrition and sanitation - all key to breaking the cycle of poverty for the next generation. In addition to targeted nutrition programmes, DFID is supporting girls through primary and secondary schools, and helping women access credit to start their own businesses. In the next four years we will:

 Support the state Governments of Bihar, Madhya Pradesh and Orissa to scale up proven, cost-effective interventions, such as: iron tablets for pregnant women, hand-washing, infant breastfeeding, Vitamin A

supplements, oral rehydration salts and management of severe malnutrition.

 Improve communities’ knowledge, behaviour, usage and monitoring of health and nutrition services by mobilising women’s groups, strengthening village health committees and initiating communication campaigns aimed at changing behaviour in the long term.

 Test new approaches and share the lessons internationally – for instance on the effect of toilets on improved child health and how communities can use fortified salt.

What results we will deliver:

 Improve health services to help 450,000 mothers deliver babies more safely with the help of nurses, midwives or doctors;

 Expand nutrition interventions in Madhya Pradesh, Orissa and Bihar that reach an additional 3.9 million children

 Ensure 5.8 million people access improved sanitation facilities, promoting better hygiene and helping prevent the spread of diarrhoea.

Scaling up nutrition in India

 

(32)

Cover image:

Tiru with her baby daughter, receiving nutrition support in southern Ethiopia, thanks to CARE International

Tanya Axisa/DFID

www.dfid.gov.uk

Figure

Updating...